Objective To determine whether very low birth weight infants (VLBWIs), initially supported with continuous positive airway pressure (CPAP) and then selectively treated with the INSURE (intubation, ...surfactant, and extubation to CPAP; CPAP/INSURE) protocol, need less mechanical ventilation than those supported with supplemental oxygen, surfactant, and mechanical ventilation if required (Oxygen/mechanical ventilation MV). Study design In a multicenter randomized controlled trial, spontaneously breathing VLBWIs weighing 800-1500 g were allocated to receive either therapy. In the CPAP/INSURE group, if respiratory distress syndrome (RDS) did not occur, CPAP was discontinued after 3-6 hours. If RDS developed and the fraction of inspired oxygen (FiO2 ) was >0.35, the INSURE protocol was indicated. Failure criteria included FiO2 >0.60, severe apnea or respiratory acidosis, and receipt of more than 2 doses of surfactant. In the Oxygen/MV group, in the presence of RDS, supplemental oxygen without CPAP was given, and if FiO2 was >0.35, surfactant and mechanical ventilation were provided. Results A total of 256 patients were randomized to either the CPAP/INSURE group (n = 131) or the Oxygen/MV group (n = 125). The need for mechanical ventilation was lower in the CPAP/INSURE group (29.8% vs 50.4%; P = .001), as was the use of surfactant (27.5% vs 46.4%; P = .002). There were no differences in death, pneumothorax, bronchopulmonary dysplasia, and other complications of prematurity between the 2 groups. Conclusion CPAP and early selective INSURE reduced the need for mechanical ventilation and surfactant in VLBWIs without increasing morbidity and death. These results may be particularly relevant for resource-limited regions.
Neonatal group B streptococcus meningitis causes neurologic morbidity and mortality. Cerebrovascular involvement is a common, poorly studied, and potentially modifiable pathologic process. We ...hypothesized that imaging patterns of focal brain infarction are recognizable in neonatal group B streptococcal meningitis. A consecutive case series included term neonates with the following: (1) bacterial meningitis, (2) acute group B streptococcal infection (positive cerebrospinal fluid/blood culture), (3) brain magnetic resonance imaging within 14 days, and (4) acute intraparenchymal focal infarctions (restricted diffusion). Lesions within known arterial territories were classified as arterial ischemic stroke. Clinical presentations, investigations, and neurologic outcomes were recorded. Eight newborns (50% female) with focal infarction were identified. Five presented early (<1 week), and all manifested clinical shock and elevated acute-phase reactants. Less than 50% had prenatal group B streptococcal screening, while 2 of 3 screened were negative. Two distinct patterns of focal infarction were identified: (1) deep perforator arterial stroke to basal ganglia, thalamus, and periventricular white matter (7/8, 88%), and (2) superficial injury with patchy, focal infarctions of the cortical surface (6/8, 75%). Outcomes (mean 23.8 months) were poor, with severe disability or death in 6/8 (75%). Recognizable stroke patterns contribute to severe neurologic outcomes and represent a potentially modifiable pathophysiologic process in neonatal group B streptococcal meningitis.
Expert consultation has been used to fill the information gaps that hamper conservation planning and nature reserve design. The use of expert knowledge in conservation planning is difficult, however, ...because it is subjective, biased, and value-laden. Decision theory provides a systematic and comprehensive means for addressing experts' subjective-and sometimes contradictory-judgments in the design of nature reserves. Thus, the experts can separate the objective criteria from the subjective components of decision making that place value on those criteria. When linked to a geographic information system (GIS), these techniques foster consensus among experts by allowing the exploration of alternative designs in an iterative way. We used such a decision-analysis approach to redesign the Monarch Butterfly Biosphere Reserve (MBBR) in central Mexico. We examined three reserve scenarios to identify the optimal overwintering habitats considering (1) an area equivalent to the previously defined boundaries of the core zone of the MBBR (4500 ha); (2) an area equivalent to the previously defined boundaries of the whole MBBR (16,000 ha); and (3) the maximum possible extent for a new core zone. This last scenario produced an area of 21,727 ha. These results were transferred to the GIS to create the respective nominal maps that were presented to the environmental authorities, who selected the third scenario for the core zone of the new MBBR. Our results allowed us to locate the prime overwintering habitats precisely and to delimit a core area for the reserve that would minimize the inclusion of forest stands valuable to local loggers.
Objectives To analyze the incidence and characteristics of benign paroxysmal positional vertigo (BPPV) in patients with Ménière's disease who did not respond to medical treatment and to whom ...intratympanic gentamycin treatment was proposed.
Study Design This is a retrospective analysis of the patients in our database. A complete otoneurologic bedside examination of each patient, including assessment of positional nystagmus, was performed at the time of diagnosis and during the follow‐up.
Results Nine of 90 patients with Ménière's disease also had BPPV, which manifested in different ways. In 3 patients, BPPV preceded the onset of Ménière's symptomatology in the same ear; in 1, BPPV manifested after treatment for Ménière's disease had ended and the patient was in complete control of the spontaneous spells of vertigo; in 5 cases, recurrences of both Ménière's disease and the positioning symptomatology coincided. Treatment for each condition was conducted independently and favorable results were obtained after long‐term follow‐up when Ménière's disease and BPPV did not coincide simultaneously. In the group manifesting symptoms of both disorders at the same time, gentamycin treatment with the Canalith Repositioning Procedure and/or Semont maneuver partially resolved the symptoms.
Conclusions In the context of Ménière's disease, the sequence of appearance of BPPV relative to the spontaneous episodes must be taken into account when planning the treatment for each of the disorders, which should be considered independently. This pattern could also influence the prognosis for each disorder.
To identify risk factors associated with tuberculin reactivity in healthcare workers (HCWs).
Cross-sectional survey of tuberculin reactivity (2 TU of purified protein derivative (PPD) RT23, using the ...Mantoux two-step test).
Two general hospitals located in a region with a high prevalence of tuberculosis and high bacille Calmette-Guerin (BCG) coverage.
Volunteer sample of HCWs.
605 HCWs were recruited: 71.2% female; mean age, 36.4 (standard deviation SD, 8.2) years; 48.9% nurses, 10.4% physicians, 26.8% administrative personnel; mean time of employment, 10.9 (SD, 6.7) years. PPD reactivity (> or =10 mm) was found in 390 (64.5%). Multivariate analysis revealed an association of tuberculin reactivity with occupational exposure in the hospital: participation in autopsies (odds ratio OR, 9.3; 95% confidence interval CI95, 2.1-40.5; P=.003.), more than 1 year of employment (OR, 2.4; CI95, 1.1-5.0; P=.02), work in the emergency or radiology departments (OR, 2.0; CI95, 1.03-3.81; P=.04), being physicians or nurses (OR, 1.5; CI95, 1.04-2.11; P=.03), age (OR, 1.04; CI95, 1.02-1.07 per year of age; P<.001), and BCG scar (OR, 2.1; CI95, 1.2-3.4; P=.005).
Although the studied population has a high baseline prevalence of tuberculosis infection and high coverage of BCG vaccination, nosocomial risk factors associated with PPD reactivity were identified as professional risks; strict early preventive measures must be implemented accordingly.
To determine markers of Taenia solium transmission and risk factors in an urban community, we studied 1,000 soldiers from a military camp in Mexico City and their relatives. Serum samples were used ...to detect antigens and antibodies and fecal specimens were examined for Taenia coproantigens and helminth eggs. Prevalences of 12.2% and 5.8% for cysticercosis were found among soldiers and their relatives, respectively. Taeniasis was found in 0.5% and none of the groups, respectively. Relatives of soldiers positive for cysticercosis and taeniasis markers ate more pork from street stores than restaurants or markets compared with relatives of soldiers without these indicators of infection. Also, 12.0% of the relatives of positive soldiers had a history of expelling tapeworm proglottids in the feces in contrast to 3.7% of the family members of the control group. Prevalence values and risk factors in this urban population are similar to those of previous studies performed in rural populations.
Leaf structure, photosynthetic characteristics and related physiological parameters have been studied in three ornamental shade species: Fatsia japonica, Cissus rhombifolia (relatively light-tolerant ...plants), and Philodendron scandens (obligate shade plant). Species were grown in a shadehouse. Maximum photosynthetic photon flux density was 470 μmol m-2s-1. Net rate of CO2uptake at light saturation (maximum Pn) in Fatsia was 6.90 ± 1.27 μmol m-2s-1. In Cissus and Philodendron values were about 30% and 63% less respectively, than those measured in Fatsia. The nitrogen content, relative dry wt, specific leaf dry wt (SLDW), chlorophyll a/b ratio, and nitrogen to chlorophyll ratio were lower in Philodendron. However, leaf thickness in Philodendron (296 ± 17 μm) was about 54% and 160% higher, respectively, than in Fatsia and Cissus, and the ratio between mesophyll cell area and leaf surface area (Ames/A) was nearly similar in the three species. However Philodendron exhibited a percentage of palisade parenchyma about three times lower than that observed in the two other species. The chloroplast number per mm of cell wall in transverse sections (chloroplast density) in the palisade parenchyma was fairly constant (about 65), irrespective of species. The "chloroplast density" in the spongy parenchyma of Philodendron was about 53% and 63%, respectively, of Fatsia and Cissus values. In Fatsia and Cissus chloroplast ultrastructure seems to change gradually and continuously from sun to shade type with the depth from the adaxial to abaxial surface. Special emphasis was given in order to determine the structural parameters best correlated with maximum Pn between the different species. In this way chloroplast number in transverse sections (chloroplast number) and the ratio between chloroplast area and leaf surface area (Achl/A) were the parameters best correlated with maximum Pn, and stomatal frequency was also a good determinant of maximum Pn. However, leaf thickness, SLDW, and even Ames/A ratio were weakly correlated with maximum Pn.
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